Public Reporting of PCI Mortality Tied to Fewer High-Risk Cases But Better Outcomes

September 24, 2015

Public reporting of PCI mortality rates results
in better procedure quality and lower risk of adverse events, including
mortality, than does collaborative quality improvement. Yet
the practice also translates into fewer high-risk patients undergoing
PCI, according to a registry study comparing 2 states that
employ the different strategies published online September 15, 2015, ahead of print in the American Heart Journal.

Drawing on the NCDR CathPCI Registry,
researchers led by Thomas F. Boyden, MD, MS, of Spectrum Health Medical Group
(Grand Rapids, MI), analyzed data on patients who underwent PCI between January
2011 and September 2012 at participating hospitals in New York, which employs
public reporting, and Michigan, which does not. The state of Michigan utilizes
a collaborative quality improvement system that provides peer-reviewed analysis
and promotes accountability through sharing of information to institutions and
providers.

Compared with Michigan patients, those in New
York were less likely to be female or white, or to have a history of MI,
congestive heart failure, hypertension, dyslipidemia, cerebrovascular disease,
PAD, and chronic lung disease. New York patients also were less likely to
undergo PCI for STEMI or NSTEMI and had lower rates of cardiogenic shock and
cardiac arrest at the time of PCI. The baseline differences resulted in a lower
percentage of patients with extremely high predicted mortality risk (> 20%) in
New York vs Michigan.

Measures of PCI quality varied between the states.
For example, a higher proportion of New York patients had PCI classified as appropriate.
However, PCI of uncertain appropriateness was more common in New York, while the
proportions of inappropriate procedures were similar between the states.

In addition, New York patients were more likely
to have markers of myonecrosis assessed but less likely to undergo pre-PCI
evaluation of renal function. At discharge, New York hospitals far less often referred
patients to cardiac rehabilitation than did Michigan hospitals (OR 0.15; 95% CI
0.14-0.16), although similar proportions of patients in the 2 states were
discharged on optimal medical therapy.

New York
Patients Fare Better

Propensity matching resulted in 2 cohorts of 40,916
patients each.Risks of vascular complications, access-site
bleeding, post-PCI transfusion, and referral for urgent, emergent, or salvage
CABG were lower in New York than in Michigan. Moreover, New York patients were
less likely to die in the hospital (table 1).

Sensitivity analyses to assess the impact of different
estimated levels of unmeasured confounders confirmed the robustness of the
mortality findings.

The authors say their observations “confirm
prior studies showing that extremely high risk patients are less likely to
undergo PCI in states with [public reporting], which may be related to risk
avoidance.”

Furthermore, observed Jeffrey W. Moses, MD, of Columbia
University Medical Center (New York, NY), in an email with TCTMD, “If an
operator has lower mortality in a low-risk population but avoids sicker people
for whom the number needed to treat is far lower, mortality for all
comers—those treated and untreated—goes up.”

Avoiding
Unintended Consequences

However, there are ways to mitigate such
“unintended consequences” of public reporting, Dr. Boyden and colleagues say. They
cite the “compassionate use criteria” incorporated into the Massachusetts PCI
reporting program, which takes into account indicators of extreme risk that may
make PCI futile and thus refines risk adjustment. Another strategy is to expand
public reporting to “highlight other important related performance measures
which may be neglected by too narrow a focus on mortality alone,” the
investigators say.

Considering the propensity-matched results, the
lower mortality rate in New York compared with Michigan is unlikely to be due
to patient mix alone, the authors contend. In fact, the comparable or better
quality of care and lower adverse events rate suggest that public reporting
“may be a strategy that still warrants consideration for improving outcomes for
PCI,” they say, adding that further study should help understand how cath lab
directors respond to public reporting so that useful strategies can be extended
to more hospitals.

“As the
[American College of Cardiology] moves towards publicly reporting mortality
statistics for PCI, and as states and the federal government increase the use
of [public reporting] for more procedures and conditions, it will be important
to closely follow use patterns to ensure that PCI is being appropriately
offered and performed,” the investigators stress.

The current results should be interpreted with certain
caveats, the authors acknowledge. For example, the benefits associated with PCI
may be affected by selection bias, as not all hospitals and health systems in
New York provide data to the NCDR, while all hospitals in Michigan do, they
say. Thus, participating hospitals in New York may represent institutions that
have more resources or provide better care than nonparticipating hospitals. In
addition, the more rigorous auditing process employed by the Michigan
collaborative quality improvement program may be better than the self-reporting
strategy used by the CathPCI Registry at accurately identifying adverse events
and clinical outcomes, Dr. Boyden and colleagues add.

In the end, the authors say, the best approach
to protecting access to care while still optimizing patient outcomes may be to
combine public reporting and collaborative quality improvement.

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